Support local leaders or risk having no leaders in future

The NHS’s current management approach favours the stick rather than the carrot, leading to huge pressures on local leaders and could undermine the success of STPs, warns Helen Buckingham

Last month, the BBC launched their NHS Tracker with the depressing news that the NHS in England, Wales and Northern Ireland had failed to achieve key standards in waiting times for emergency care, cancer care and planned surgery for the last 18 months.

In September, we saw two trust chief executives resign suddenly due to poor accident and emergency performance, and few weeks have gone by without the resignation of at least one clinical commissioning group leader, closely associated with reports of poor performance on finances or targets – or both – in their areas.

Only last weekend, we read that Theresa May is reportedly holding Simon Stevens personally accountable for the performance of the NHS this winter.

Skewed approach

Our report today is set in this context. A year ago, the Nuffield Trust set out to find out how CCG accountable officers and local leaders in NHS England felt as they tried to find the right balance around accountability, autonomy and performance management – both to deliver now and for future strategic change.

It won’t surprise many that a significant proportion of the leaders we spoke to felt the current approach to recognising accountability and managing performance could be described as skewed to the stick, rather than the carrot. As one NHS England leader noted ruefully:

“There’s a quality angle to the role but if you looked at my diary, about 80 per cent of my time is spent on performance management.”

Most energy was spent addressing current performance and financial pressures, rather than on supporting CCGs and local systems with longer term approaches more likely to deliver sustainable change

We found that most energy was spent addressing current performance and financial pressures, rather than on supporting CCGs and local systems with longer term approaches more likely to deliver sustainable change but that take time to show results.

With NHS commissioning organisations in England already restructured seven times since the early 1990s – each iteration looking to improve the accountability and performance management systems that came before – sustainability and transformation partnerships, accountable care organisations and accountable care systems are an eighth change.

Remedial measures

How can we learn from past lessons?

The national bodies have recognised many of the issues described in our report, and set out plans to address them.

NHS England and NHS Improvement have agreed to test the appointment of joint regional directors in the south of England, and there are already joint nurse directors in London and the south.

Over winter, each STP area will be overseen by a single regional director acting on behalf of both NHS England and NHS Improvement, and there will be a single escalation framework, overseen by the joint national director of urgent and emergency care.

But whatever the structure, ultimately it is leadership behaviour that will have a long term impact on organisations and systems.

Whatever the structure, ultimately it is leadership behaviour that will have a long term impact on organisations and systems.

Honouring these pledges is essential for STPs, ACSs and ACOs to realise their potential. It is extraordinarily difficult to do this with such huge operational pressure in the service, but that only magnifies how important it is to support local leaders tackling those pressures every day.

A year on from our interviews and publishing the National Framework, have things really changed?

There is great work going on in parts of NHS England and NHS Improvement to foster innovation and quality improvement, and to support local leaders in making change on the ground, such as through the work of the new care models team at NHS England, or the nursing team at NHS Improvement.

Dissonance between actions and words

But there also continue to be examples of pretty robust “directive” and “pace setting” management – an approach described by HSJ’s Andy Cowper as ”management by admonishment”.

We are still seeing responses to urgent short term imperatives crowd out the time needed for important long term work.

We are still seeing the NHS and local authorities enjoined to collaborate at a local level while actions taken nationally heighten tensions in those relationships.

There is a dissonance between actions and words, and people leading local organisations feel that.

We are still seeing the NHS and local authorities enjoined to collaborate at a local level while actions taken nationally heighten tensions in those relationships.

And that makes their job harder. One of the striking points from our interviews was the responsibility leaders felt about supporting their staff through more change and more pressure. We see that too in leaders of provider organisations making recent statements on social media about the pressures on frontline staff.

The NHS Constitution states that “it is the commitment, professionalism and dedication of staff working for the benefit of the people the NHS serves that really make the difference”.

The leaders in CCGs, trusts and STPs count among those staff, and we must not take their professionalism and dedication for granted. If we are not able to look after the leaders of the organisations we have now, we risk having no leaders for the organisations of the future.

Senior members of an inadequate clinical commissioning group have said directors’ ability to carry out their jobs is hampered because of extra work related to their sustainability and transformation partnership.

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